Embryology and anatomy of anorectal malformations Miyake, Yuichiro; Lane, Geoffrey J.; Yamataka, Atsuyuki
Seminars in pediatric surgery,
December 2022, 2022-Dec, 2022-12-00, 20221201, Letnik:
31, Številka:
6
Journal Article
Recenzirano
The etiology of anorectal malformations (ARM) is complicated because of the spectrum of anomalies seen clinically, many of which are isolated and seemingly unique. Recent studies suggest that ARMs ...result from abnormal cloacal membrane (CM) development that contributes to disrupt normal local muscle and nerve development. If CM maldevelopment is severe, the rectal pouch lies above the pelvic floor, resulting in asymmetric and/or deviated musculature, so a midline incision is likely to cause trauma or be detrimental. Autonomic nerve plexuses can be associated with a fistula tract in ARMs and are also at risk for damage during surgery and contribute to genitourinary complications. Understanding the anatomy and development of the perineum is crucial for treating the broad spectrum of anomalies associated with ARMs and may assist in predicting/managing other related morbidity.
Aim
We compared robotic hepaticojejunostomy anastomosis (RHJA) with laparoscopic hepaticojejunostomy anastomosis (LHJA) in children undergoing complete excision of choledochal cyst.
Methods
...Difficulty of suturing (DOS) during anastomosis was scored blindly, from intraoperative video recordings, using: 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; and 1 = easy. A panel of fiveindependent surgeons was also asked to compare RHJA with matched LHJA and score + 1 if RHJA appeared superior to LHJA, 0 if RHJA appeared equivalent to LHJA, and − 1 if RHJA appeared inferior to LHJA.
Results
RHJA (
n
= 10) was performed between 2017 and 2019; LHJA (
n
= 27) was performed between 2009 and 2018. LHJA cases were matched for age, weight, and anastomosis diameter to RHJA cases. Complete excision was performed laparoscopically in both groups. DOS was lower in RHJA with less variance. The panel all scored RHJA as + 1. Total anastomotic time (TAT) and TAT per suture were significantly shorter for RHJA. Times taken to ambulate and for return of bowel sounds postoperatively were significantly shorter for RHJA. There was one anastomotic leak with LHJA (3.7%) and no anastomotic complications with RHJA.
Conclusions
RHJA is a more stable anastomosis that can be performed quicker, and thus, would appear to be superior to LHJA.
•In a series of laparoscopic choledochal cyst operations, 4 K imaging was rated as being superior to 2 K imaging by a panel of independent assessors.•4 K imaging enhanced performance appeared to be ...owing to improved resolution.•4 K imaging reduced total cyst excision and operative times significantly.•4 K imaging lowered coefficients of variation during cyst excision and suturing.
The safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.
LapCC were performed at a single institution by the same team using a 2 K system (2009–2018; n = 26) and a 4 K system (2018–2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.
LapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p<0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p < 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22).
There was one HJA leak with 2 K (3.8%) and no complications with 4 K.
Improved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.
III.
The value of intraoperative bronchoscopic inspection (IBI) for accurate confirmation of the location and distance between the distal tracheoesophageal fistula (TEF) and the proximal blind end of the ...esophagus (GAP) was evaluated in Type C esophageal atresia (EA)+TEF.
IBI involved inserting the tip of a bronchoscope into the TEF and a nasogastric tube into the blind end of the EA and measuring GAP with fluoroscopy. EA+TEF patients (
= 23) treated thoracoscopically between 2007 and 2020 were classified according to IBI as IBI+ (
= 16) and IBI- (
= 7) to compare demographics, operative time, and time taken for TEF division.
Demographics were similar. Mean time for TEF division (15.4 ± 4.6 minutes for IBI+ versus 38.6 ± 20.9 minutes for IBI-;
< .05) and mean operative time (215.3 ± 48.9 minutes for IBI+ versus 286.4 ± 51.7 minutes for IBI+;
< .05) were significantly shorter. Mean GAP measured radiographically was 0.5 cm (range: 0-1.2 cm); mean GAP measured with IBI was 0.9 cm (range: 0-2.2 cm). Postoperative complications were 3 anastomotic leakages (1/16 in IBI+ and 2/7 in IBI-) that resolved without surgery and 8 strictures (3/16 in IBI+ and 5/7 in IBI-) treated by dilatation.
IBI was effective for measuring GAP and is recommended for improving the efficiency of thoracoscopic repair.
Purpose
Screening for undescended testis (UDT) in Japan is performed as a neonate, then at 1, 3, 10, and 18 months old, and 3 years old. Incidence of ascending testis (AT) after screening was ...reviewed.
Methods
All orchiopexy/orchiectomy at a single institute between July 2005 and June 2022 were reviewed retrospectively.
Results
376 boys had 422 procedures; 54/422 (12.8%) were in 48 boys ≥ 4 years old (mean age: 6.7 years; range: 4–13); testes were normal (
n
= 22; 40.7%), small (
n
= 25; 46.2%), or atrophied (
n
= 7; 1.3%). There were 47 orchiopexies and 7 orchiectomies for atrophy. Incidence of AT in boys ≥ 4 years old was 24/422 (5.7%). Of these, 16/422 (3.8%) developed after normal descent and 8/422 (1.9%) were associated with retractile testis (AT + RET). Other indications included delayed treatment for UDT (
n
= 13), late referral by pediatricians (
n
= 10), and iatrogenic UDT (
n
= 6).
Surgical intervention in boys ≥ 4 years old (12.8%) was less than that reported in the West (range: 30–50%) as was AT: (5.7% versus 15.4%) and AT + RET (1.9% versus 13.8%).
Conclusions
Comprehensive UDT screening probably contributed to the lower incidence of surgery and AT (especially AT + RET) in boys ≥ 4 years old.
Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor ...end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic.
We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP.
Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 95% confidence interval, 1.05-1.82). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP.
Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.
A biopsy protocol for diagnosing Hirschsprung's disease (HD) in children using the anorectal line (ARL).
The ARL was adopted for diagnosing HD in 2016 using two excisional submucosal rectal biopsies ...performed at different levels, sequentially; the first just above the ARL and the second, further proximal (2-ARL). Currently, only the first-level biopsy is performed (1-ARL) and examined intraoperatively. Management was observation if normoganglionic, pull-through if aganglionic, and a second-level biopsy if hypoganglionic. Hypoganglionosis was considered physiologic if the second-level biopsy was normoganglionic and pathologic if hypoganglionic. Colon caliber change and bowel obstructive symptoms reflect the severity of hypoganglionosis.
For 2-ARL (
= 54), results were: normoganglionosis (
= 31/54; 57.4%), aganglionosis (
= 19/54; 35.2%), and hypoganglionosis (
= 4/54; 7.4%); physiologic (
= 3/54; 5.6%) and pathologic (
= 1/54; 1.9%). Normoganglionosis and aganglionosis were always duplicated in 2-ARL (kappa = 1.0). For 1-ARL (
= 36), results were: normoganglionosis (
= 17/36; 47.2%), aganglionosis (
= 17/36; 47.2%), and hypoganglionosis (
= 2/36; 5.6%). Second-level biopsies were normoganglionic (physiologic:
= 1) and hypoganglionic (pathologic:
= 1). All normoganglionic cases, except one, resolved conservatively. All aganglionic cases had pull-through with HD confirmed on histopathology. Both pathologic hypoganglionic cases had caliber change and severe obstructive symptoms as definitive indications for pull-through with hypoganglionosis of the entire rectum confirmed on histopathology. Physiologic hypoganglionic cases were observed and currently have regular defecation.
Because the ARL is an objective functional, neurologic, and anatomic demarcation, normoganglionosis and aganglionosis can be diagnosed accurately with a single excisional biopsy. Only hypoganglionosis requires a second-level biopsy.
